Nebulizer

Another form of nebulization

Guidelines

Various asthma guidelines, such as the Global Initiative for Asthma Guidelines [GINA], the British Guidelines on the management of Asthma, The Canadian Pediatric Asthma Consensus Guidelines, and United States Guidelines for Diagnosis and Treatment of Asthma each recommend metered dose inhalers in place of nebulizer-delivered therapies.^[3] The European Respiratory Society acknowledge that although nebulizers are used in hospitals and at home they suggest much of this use may not be evidence-based.^[4]

Effectiveness

Recent evidence shows that nebulizers are no more effective than metered-dose inhalers (MDIs) with spacers.^[5] An MDI with a spacer may offer advantages to children who have acute asthma.^[3][6][5] Those findings refer specifically to the treatment of asthma and not to the efficacy of nebulisers generally, as for COPD for example.^[5] For COPD, especially when assessing exacerbations or lung attacks, there is no evidence to indicate that MDI (with a spacer) delivered medicine is more effective than administration of the same medicine with a nebulizer.^[7]

The European Respiratory Society highlighted a risk relating to droplet size reproducibility caused by selling nebulizer devices separately from nebulized solution. They found this practice could vary droplet size 10-fold or more by changing from an inefficient nebulizer system to a highly efficient one.^[4][5] Two advantages attributed to nebulizers, compared to MDIs with spacers (inhalers), are their ability to deliver larger dosages at a faster rate, especially in acute asthma; however, recent data suggests actual lung deposition rates are the same. In addition, another trial found that a MDI (with spacer) had a lower required dose for clinical result compared to a nebulizer (see Clark, et al. other references).^[3]

Beyond use in chronic lung disease, nebulizers may also be used to treat acute issues like the inhalation of toxic substances. One such example is the treatment of inhalation of toxic hydrofluoric acid (HF) vapors.^[8] Calcium gluconate is a first-line treatment for HF exposure to the skin. By using a nebulizer, calcium gluconate is delivered to the lungs as an aerosol to counteract the toxicity of inhaled HF vapors.

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Metered-dose inhaler

Metered-dose inhaler

A metered-dose inhaler (MDI) is a device that delivers a specific amount of medication to the lungs, in the form of a short burst of aerosolized medicine that is usually self-administered by the patient via inhalation. It is the most commonly used delivery system for treating asthma, chronic obstructive pulmonary disease (COPD) and other respiratory diseases. The medication in a metered dose inhaler is most commonly a bronchodilator, corticosteroid or a combination of both for the treatment of asthma and COPD. Other medications less commonly used but also administered by MDI are mast cell stabilizers, such as cromoglicate or nedocromil.

European Respiratory Society

European Respiratory Society

The European Respiratory Society, or ERS, is a non-profit organization with offices in Lausanne, Brussels and Sheffield. It was founded in 1990 in the field of respiratory medicine. The organization was formed with the merger of the Societas Europaea Physiologiae Clinicae Respoiratoriae and the European Society of Pneumology. The organization's membership is made up of medical professionals and scientists working in the area of respiratory medicine.

Hydrofluoric acid

Hydrofluoric acid

Hydrofluoric acid is a solution of hydrogen fluoride (HF) in water. Solutions of HF are colourless, acidic and highly corrosive. It is used to make most fluorine-containing compounds; examples include the commonly used pharmaceutical antidepressant medication fluoxetine (Prozac) and the material PTFE (Teflon). Elemental fluorine is produced from it. It is commonly used to etch glass and silicon wafers.

Calcium gluconate

Calcium gluconate

Calcium gluconate is the calcium salt of gluconic acid and is used as a mineral supplement and medication. As a medication it is used by injection into a vein to treat low blood calcium, high blood potassium, and magnesium toxicity. Supplementation is generally only required when there is not enough calcium in the diet. Supplementation may be done to treat or prevent osteoporosis or rickets. It can also be taken by mouth but is not recommended for injection into a muscle.

The lung deposition characteristics and efficacy of an aerosol depend largely on the particle or droplet size. Generally, the smaller the particle the greater its chance of peripheral penetration and retention. However, for very fine particles below 0.5 μm in diameter there is a chance of avoiding deposition altogether and being exhaled. In 1966 the Task Group on Lung Dynamics, concerned mainly with the hazards of inhalation of environmental toxins, proposed a model for deposition of particles in the lung. This suggested that particles of more than 10 μm in diameter are most likely to deposit in the mouth and throat, for those of 5–10 μm diameter a transition from mouth to airway deposition occurs, and particles smaller than 5 μm in diameter deposit more frequently in the lower airways and are appropriate for pharmaceutical aerosols.^[9] Nebulizing processes have been modeled using computational fluid dynamics.^[10]

A modern jet nebulizer

A vial of 0.5% albuterol sulfate inhalation solution for nebulizing

Pneumatic

Jet nebulizer

The most commonly used nebulizers are jet nebulizers, which are also called "atomizers".^[11] Jet nebulizers are connected by tubing to a supply of compressed gas, usually compressed air or oxygen to flow at high velocity through a liquid medicine to turn it into an aerosol that is inhaled by the patient. Currently there seems to be a tendency among physicians to prefer prescription of a pressurized Metered Dose Inhaler (pMDI) for their patients, instead of a jet nebulizer that generates a lot more noise (often 60 dB during use) and is less portable due to a greater weight. However, jet nebulizers are commonly used in hospitals for patients who have difficulty using inhalers, such as in serious cases of respiratory disease, or severe asthma attacks.^[12] The main advantage of the jet nebulizer is related to its low operational cost. If the patient needs to inhale medicine on a daily basis the use of a pMDI can be rather expensive. Today several manufacturers have also managed to lower the weight of the jet nebulizer to 635 grams (22.4 oz), and thereby started to label it as a portable device. Compared to all the competing inhalers and nebulizers, the noise and heavy weight is still the biggest draw back of the jet nebulizer.^[13]

Mechanical

Soft mist inhaler

The medical company Boehringer Ingelheim also invented a device named Respimat Soft Mist Inhaler in 1997. This new technology provides a metered dose to the user, as the liquid bottom of the inhaler is rotated clockwise 180 degrees by hand, adding a build up tension into a spring around the flexible liquid container. When the user activates the bottom of the inhaler, the energy from the spring is released and imposes pressure on the flexible liquid container, causing liquid to spray out of 2 nozzles, thus forming a soft mist to be inhaled. The device features no gas propellant and no need for battery/power to operate. The average droplet size in the mist was measured to 5.8 micrometers, which could indicate some potential efficiency problems for the inhaled medicine to reach the lungs. Subsequent trials have proven this was not the case. Due to the very low velocity of the mist, the Soft Mist Inhaler in fact has a higher efficiency compared to a conventional pMDI.^[14] In 2000, arguments were launched towards the European Respiratory Society (ERS) to clarify/expand their definition of a nebulizer, as the new Soft Mist Inhaler in technical terms both could be classified as a "hand driven nebulizer" and a "hand driven pMDI".^[15]

Electrical

Ultrasonic wave nebulizer

Ultrasonic wave nebulizers were invented in 1965^[16] as a new type of portable nebulizer. The technology inside an ultrasonic wave nebulizer is to have an electronic oscillator generate a high frequency ultrasonic wave, which causes the mechanical vibration of a piezoelectric element. This vibrating element is in contact with a liquid reservoir and its high frequency vibration is sufficient to produce a vapor mist.^[17] As they create aerosols from ultrasonic vibration instead of using a heavy air compressor, they only have a weight around 170 grams (6.0 oz). Another advantage is that the ultrasonic vibration is almost silent. Examples of these more modern type of nebulizers are: Omron NE-U17 and Beurer Nebulizer IH30.^[18]

Vibrating mesh technology

A new significant innovation was made in the nebulizer market around 2005, with creation of the ultrasonic Vibrating Mesh Technology (VMT). With this technology a mesh/membrane with 1000–7000 laser drilled holes vibrates at the top of the liquid reservoir, and thereby pressures out a mist of very fine droplets through the holes. This technology is more efficient than having a vibrating piezoelectric element at the bottom of the liquid reservoir, and thereby shorter treatment times are also achieved. The old problems found with the ultrasonic wave nebulizer, having too much liquid waste and undesired heating of the medical liquid, have also been solved by the new vibrating mesh nebulizers. Available VMT nebulizers include: Pari eFlow,^[19] Respironics i-Neb,^[20] Beurer Nebulizer IH50,^[21] and Aerogen Aeroneb.^[22] As the price of the ultrasonic VMT nebulizers is higher than models using previous technologies, most manufacturers continue to also sell the classic jet nebulizers.^[23]

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Compressed air

Compressed air

Compressed air is air kept under a pressure that is greater than atmospheric pressure. Compressed air is an important medium for transfer of energy in industrial processes, and is used for power tools such as air hammers, drills, wrenches, and others, as well as to atomize paint, to operate air cylinders for automation, and can also be used to propel vehicles. Brakes applied by compressed air made large railway trains safer and more efficient to operate. Compressed air brakes are also found on large highway vehicles.

Oxygen

Oxygen

Oxygen is the chemical element with the symbol O and atomic number 8. It is a member of the chalcogen group in the periodic table, a highly reactive nonmetal, and an oxidizing agent that readily forms oxides with most elements as well as with other compounds. Oxygen is Earth's most abundant element, and after hydrogen and helium, it is the third-most abundant element in the universe. At standard temperature and pressure, two atoms of the element bind to form dioxygen, a colorless and odorless diatomic gas with the formula O2. Diatomic oxygen gas currently constitutes 20.95% of the Earth's atmosphere, though this has changed considerably over long periods of time. Oxygen makes up almost half of the Earth's crust in the form of oxides.

Aerosol

Aerosol

An aerosol is a suspension of fine solid particles or liquid droplets in air or another gas. Aerosols can be natural or anthropogenic. Examples of natural aerosols are fog or mist, dust, forest exudates, and geyser steam. Examples of anthropogenic aerosols include particulate air pollutants, mist from the discharge at hydroelectric dams, irrigation mist, perfume from atomizers, smoke, dust, steam from a kettle, sprayed pesticides, and medical treatments for respiratory illnesses. When a person inhales the contents of a vape pen or e-cigarette, they are inhaling an anthropogenic aerosol.

Boehringer Ingelheim

Boehringer Ingelheim

C.H. Boehringer Sohn AG & Co. KG is the parent company of the Boehringer Ingelheim group, which was founded in 1885 by Albert Boehringer (1861–1939) in Ingelheim am Rhein, Germany. As of 2018, Boehringer Ingelheim is one of the world's largest pharmaceutical companies, and the largest private one. Headquartered in Ingelheim, it operates globally with 146 affiliates and more than 47,700 employees. Unlike most large pharmaceutical companies which are listed, the company is private and fully owned by the Boehringer, Liebrecht and von Baumbach families. The company's key areas of interest are: respiratory diseases, metabolism, immunology, oncology and diseases of the central nervous system. Boehringer Ingelheim is a full member of the European Federation of Pharmaceutical Industries and Associations (EFPIA). The corporate logo of Boehringer Ingelheim depicts a stylized rendition of the central section of the imperial palace of Charlemagne.

Respimat

Respimat

Respimat, also known as Respimat Soft Mist Inhaler, is a drug delivery device used for the treatment of asthma, chronic obstructive pulmonary disease (COPD), and other respiratory conditions.

Electronic oscillator

Electronic oscillator

An electronic oscillator is an electronic circuit that produces a periodic, oscillating electronic signal, often a sine wave or a square wave or a triangle wave. Oscillators convert direct current (DC) from a power supply to an alternating current (AC) signal. They are widely used in many electronic devices ranging from simplest clock generators to digital instruments and complex computers and peripherals etc. Common examples of signals generated by oscillators include signals broadcast by radio and television transmitters, clock signals that regulate computers and quartz clocks, and the sounds produced by electronic beepers and video games.

Omron

Omron

Omron Corporation , styled as OMRON, is a Japanese electronics company based in Kyoto, Japan. Omron was established by Kazuma Tateishi (立石一真) in 1933 and incorporated in 1948.

Respironics

Respironics

Respironics is an American medical supply company owned by Philips that specializes in products that improve respiratory functions. It is based in the Pittsburgh suburb of Murrysville in Pennsylvania, United States.

Nebulizers accept their medicine in the form of a liquid solution, which is often loaded into the device upon use. Corticosteroids and bronchodilators such as salbutamol (albuterol USAN) are often used, and sometimes in combination with ipratropium. The reason these pharmaceuticals are inhaled instead of ingested is in order to target their effect to the respiratory tract, which speeds onset of action of the medicine and reduces side effects, compared to other alternative intake routes.^[12]

Usually, the aerosolized medicine is inhaled through a tube-like mouthpiece, similar to that of an inhaler. The mouthpiece, however, is sometimes replaced with a face mask, similar to that used for inhaled anesthesia, for ease of use with young children or the elderly. Pediatric masks are often shaped like animals such as fish, dogs or dragons to make children less resistant to nebulizer treatments. Many nebulizer manufacturers also offer pacifier attachments for infants and toddlers. But mouthpieces are preferable if patients are able to use them since face-masks result in reduced lung delivery because of aerosol losses in the nose.^[11]

After use with corticosteroid, it is theoretically possible for patients to develop a yeast infection in the mouth (thrush) or hoarseness of voice (dysphonia), although these conditions are clinically very rare. To avoid these adverse effects, some clinicians suggest that the person who used the nebulizer should rinse his or her mouth. This is not true for bronchodilators; however, patients may still wish to rinse their mouths due to the unpleasant taste of some bronchodilating drugs.

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Bronchodilator

Bronchodilator

A bronchodilator or broncholytic is a substance that dilates the bronchi and bronchioles, decreasing resistance in the respiratory airway and increasing airflow to the lungs. Bronchodilators may be originating naturally within the body, or they may be medications administered for the treatment of breathing difficulties, usually in the form of inhalers. They are most useful in obstructive lung diseases, of which asthma and chronic obstructive pulmonary disease are the most common conditions. Although this remains somewhat controversial, they might be useful in bronchiolitis and bronchiectasis. They are often prescribed but of unproven significance in restrictive lung diseases.

Salbutamol

Salbutamol

Salbutamol, also known as albuterol and sold under the brand name Ventolin among others, is a medication that opens up the medium and large airways in the lungs. It is a short-acting β2 adrenergic receptor agonist which works by causing relaxation of airway smooth muscle. It is used to treat asthma, including asthma attacks, exercise-induced bronchoconstriction, and chronic obstructive pulmonary disease (COPD). It may also be used to treat high blood potassium levels. Salbutamol is usually used with an inhaler or nebulizer, but it is also available in a pill, liquid, and intravenous solution. Onset of action of the inhaled version is typically within 15 minutes and lasts for two to six hours.

United States Adopted Name

United States Adopted Name

A United States Adopted Name (USAN) is a unique nonproprietary name assigned to a medication marketed in the United States. Each name is assigned by the USAN Council, which is co-sponsored by the American Medical Association (AMA), the United States Pharmacopeial Convention (USP), and the American Pharmacists Association (APhA).

Respiratory tract

Respiratory tract

The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa.

Inhaler

Inhaler

An inhaler is a medical device used for delivering medicines into the lungs through the work of a person's breathing. This allows medicines to be delivered to and absorbed in the lungs, which provides the ability for targeted medical treatment to this specific region of the body, as well as a reduction in the side effects of oral medications. There are a wide variety of inhalers, and they are commonly used to treat numerous medical conditions with asthma and chronic obstructive pulmonary disease (COPD) being among the most notable.

Anesthesia

Anesthesia

Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia, paralysis, amnesia, and unconsciousness. An individual under the effects of anesthetic drugs is referred to as being anesthetized.

Oral candidiasis

Oral candidiasis

Oral candidiasis, also known as oral thrush among other names, is candidiasis that occurs in the mouth. That is, oral candidiasis is a mycosis of Candida species on the mucous membranes of the mouth.

Sales-Girons pressurized nebulizer from 1858

The first "powered" or pressurized inhaler was invented in France by Sales-Girons in 1858.^[24] This device used pressure to atomize the liquid medication. The pump handle is operated like a bicycle pump. When the pump is pulled up, it draws liquid from the reservoir, and upon the force of the user's hand, the liquid is pressurized through an atomizer, to be sprayed out for inhalation near the user's mouth.^[25]

In 1864, the first steam-driven nebulizer was invented in Germany. This inhaler, known as "Siegle's steam spray inhaler", used the Venturi principle to atomize liquid medication, and this was the very beginning of nebulizer therapy. The importance of droplet size was not yet understood, so the efficacy of this first device was unfortunately mediocre for many of the medical compounds. The Siegle steam spray inhaler consisted of a spirit burner, which boiled water in the reservoir into steam that could then flow across the top and into a tube suspended in the pharmaceutical solution. The passage of steam drew the medicine into the vapor, and the patient inhaled this vapor through a mouthpiece made of glass.^[26]

The first pneumatic nebulizer fed from an electrically driven gas (air) compressor was invented in the 1930s and called a Pneumostat. With this device, a medical liquid (typically epinephrine chloride, used as a bronchial muscle relaxant to reverse constriction).^[27] As an alternative to the expensive electrical nebulizer, many people in the 1930s continued to use the much more simple and cheap hand-driven nebulizer, known as the Parke-Davis Glaseptic.^[28]

In 1956, a technology competing against the nebulizer was launched by Riker Laboratories (3M), in the form of pressurized metered-dose inhalers, with Medihaler-iso (isoprenaline) and Medihaler-epi (epinephrine) as the two first products.^[29] In these devices, the drug is cold-fill and delivered in exact doses through some special metering valves, driven by a gas propellant technology (i.e. Freon or a less environmentally damaging HFA).^[24]

In 1964, a new type of electronic nebulizer was introduced: the "ultrasonic wave nebulizer".^[30] Today the nebulizing technology is not only used for medical purposes. Ultrasonic wave nebulizers are also used in humidifiers, to spray out water aerosols to moisten dry air in buildings.^[17]

Some of the first models of electronic cigarettes featured an ultrasonic wave nebulizer (having a piezoelectric element vibrating and creating high-frequency ultrasound waves, to cause vibration and atomization of liquid nicotine) in combination with a vapouriser (built as a spray nozzle with an electric heating element).^[31] The most common type of electronic cigarettes currently sold, however, omit the ultrasonic wave nebulizer, as it was not found to be efficient enough for this kind of device. Instead, the electronic cigarettes now use an electric vaporizer, either in direct contact with the absorbent material in the "impregnated atomizer," or in combination with the nebulization technology related to a "spraying jet atomizer" (in the form of liquid droplets being out-sprayed by a high-speed air stream, that passes through some small venturi injection channels, drilled in a material absorbed with nicotine liquid).^[32]

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Epinephrine (medication)

Epinephrine (medication)

Epinephrine, also known as adrenaline, is a medication and hormone. As a medication, it is used to treat several conditions, including anaphylaxis, cardiac arrest, asthma, and superficial bleeding. Inhaled epinephrine may be used to improve the symptoms of croup. It may also be used for asthma when other treatments are not effective. It is given intravenously, by injection into a muscle, by inhalation, or by injection just under the skin.

3M

3M

3M is an American multinational conglomerate operating in the fields of industry, worker safety, healthcare, and consumer goods. The company produces over 60,000 products under several brands, including adhesives, abrasives, laminates, passive fire protection, personal protective equipment, window films, paint protection films, dental and orthodontic products, electrical and electronic connecting and insulating materials, medical products, car-care products, electronic circuits, healthcare software and optical films. It is based in Maplewood, a suburb of Saint Paul, Minnesota.

Metered-dose inhaler

Metered-dose inhaler

A metered-dose inhaler (MDI) is a device that delivers a specific amount of medication to the lungs, in the form of a short burst of aerosolized medicine that is usually self-administered by the patient via inhalation. It is the most commonly used delivery system for treating asthma, chronic obstructive pulmonary disease (COPD) and other respiratory diseases. The medication in a metered dose inhaler is most commonly a bronchodilator, corticosteroid or a combination of both for the treatment of asthma and COPD. Other medications less commonly used but also administered by MDI are mast cell stabilizers, such as cromoglicate or nedocromil.

Isoprenaline

Isoprenaline

Isoprenaline, or isoproterenol, is a medication used for the treatment of bradycardia, heart block, and rarely for asthma. It is a non-selective β adrenoceptor agonist that is the isopropylamine analog of epinephrine (adrenaline).

Freon

Freon

Freon is a registered trademark of the Chemours Company and generic descriptor for a number of halocarbon products. They are stable, nonflammable, low toxicity gases or liquids which have generally been used as refrigerants and as aerosol propellants. These include the chlorofluorocarbons (CFCs) that cause ozone depletion and HCFCs. Not all refrigerants of this type are labelled as "Freon" since Freon is a brand name for the refrigerants R-12, R-13B1, R-22, R-410A, R-502, and R-503 manufactured by The Chemours Company. Freon emits a strong chemical smell similar to acetone, a nail polish remover component.

Humidifier

Humidifier

A humidifier is a device, primarily an electrical appliance, that increases humidity (moisture) in a single room or an entire building. In the home, point-of-use what humidifiers are commonly used to humidify a single room, while whole-house or furnace humidifiers, which connect to a home's HVAC system, provide humidity to the entire house. Medical ventilators often include humidifiers for increased patient comfort. Large humidifiers are used in commercial, institutional, or industrial contexts, often as part of a larger HVAC system.

Electronic cigarette

Electronic cigarette

An electronic cigarette is an electronic device that simulates tobacco smoking. It consists of an atomizer, a power source such as a battery, and a container such as a cartridge or tank. Instead of smoke, the user inhales vapor. As such, using an e-cigarette is often called "vaping". The atomizer is a heating element that vaporizes a liquid solution called e-liquid, which quickly cools into an aerosol of tiny droplets, vapor and air. E-cigarettes are activated by taking a puff or pressing a button. Some look like traditional cigarettes, and most kinds are reusable. The vapor mainly comprises propylene glycol and/or glycerin, usually with nicotine and flavoring. Its exact composition varies, and depends on several things including user behavior.

Ultrasound

Ultrasound

Ultrasound is sound with frequencies greater than 20 kilohertz. This frequency is the approximate upper audible limit of human hearing in healthy young adults. The physical principles of acoustic waves apply to any frequency range, including ultrasound. Ultrasonic devices operate with frequencies from 20 kHz up to several gigahertz.

Nicotine

Nicotine

Nicotine is a naturally produced alkaloid in the nightshade family of plants and is widely used recreationally as a stimulant and anxiolytic. As a pharmaceutical drug, it is used for smoking cessation to relieve withdrawal symptoms. Nicotine acts as a receptor agonist at most nicotinic acetylcholine receptors (nAChRs), except at two nicotinic receptor subunits where it acts as a receptor antagonist.

Spray nozzle

Spray nozzle

A spray nozzle or atomizer is a device that facilitates the dispersion of a liquid by the formation of a spray. The production of a spray requires the fragmentation of liquid structures, such as liquid sheets or ligaments, into droplets, often by using kinetic energy to overcome the cost of creating additional surface area. A wide variety of spray nozzles exist, that make use of one or multiple liquid breakup mechanisms, which can be divided into three categories: liquid sheet breakup, jets and capillary waves. Spray nozzles are of great importance for many applications, where the spray nozzle is designed to have the right spray characteristics.

Heating element

Heating element

A heating element converts electrical energy into heat through the process of Joule heating. Electric current through the element encounters resistance, resulting in heating of the element. Unlike the Peltier effect, this process is independent of the direction of current.